Weight Loss Questionnaire

Take this quiz and get a personalized wellness profile with product recommendations and advice that can help you look and feel great and enjoy the good health you deserve. Plus for filling out the Health Questionaire and giving My Herbal Secrets permission to contact you, we will send you a Free Weight Loss Sample Pack with Literature

One Sample Pack per household, limited time offer.
Offer applies to Weightloss Sample Pack Only, with Consultation.
There is a $19.95 shipping and handling fee.

Contact Information

Contact Information
1. Name*

Name*
Address, City, State, Zip*

Address, City, State, Zip*
2. Phone Number / Best Time To Contact ?*

Phone Number / Best Time To Contact ?*
Email Address*

Email Address*
Eating Habits

Eating Habits

1. Which of the following best describes your eating habits?



Weight management

Weight management

2. How much weight (if any) would you like to lose?





Shape management

Shape management

3. Where do you tend to store your excess weight?


Snacking

Snacking

4. Which of the following best describes you?


Activity Level

Activity Level

5. Which of the following best describes your activity level?



Digestive Health

Digestive Health

6. Do you suffer from constipation and/or indigestion?


Stress

Stress

7. How stressful is your life?


Energy

Energy

8. How would you describe your energy level?


Heart Health

Heart Health

9. How concerned are you about heart health?


Anti-aging

Anti-aging

10. How concerned are you about the visible signs of aging?


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